The productivity of physician assistants and nurse practitioners and health work force policy in the era of managed health care

Managed care is spreading rapidly in the United States and creating incentives for physician practices to find the most efficient combination of health professionals to deliver care to an enrolled population. Given these trends, it is appropriate to reexamine the roles of physician assistants (PAs) and nurse practitioners (NPs) in the health care workforce. This paper briefly reviews the literature on PA and NP productivity, managed care plans' use of PAs and NPs, and the potential impact of PAs and NPs on the size and composition of the future physician workforce. In general, the literature supports the idea that PAs and NPs could have a major impact on the future health care workforce. Studies show significant opportunities for increased physician substitution and even conservative assumptions about physician task delegation imply a large increase in the number of PAs and NPs that can be effectively deployed. However, the current literature has certain limitations that make it difficult to quantify the future impact of PAs and NPs. Among these limitations is the fact that virtually all formal productivity studies were conducted in fee-for-service settings during the 1970s, rather than managed care settings. In addition, the vast majority of PA and NP productivity studies have viewed PAs and NPs as physician substitutes rather than as members of interdisciplinary health care teams, which may become the dominant health care delivery model over the next 10-20 years.     

Sports medicine. 5. The physiatrist as team physician

This self-directed learning module highlights important aspects of the evaluation and care of the injured athlete by a team physician. It is part of the chapter on sports medicine in the Self-Directed Medical Knowledge Program for practitioners and trainees in physical medicine and rehabilitation. This article covers the components of a preparticipation examination, the on-field evaluation of head, spine, and limb injuries, and return-to-play criteria after specific injuries. Sports medicine for the physically challenged athlete, medicolegal considerations for the team physician, and anabolic steroids are also reviewed.     

Managing time for greater effectiveness: designing doctor''s ideal day

We cannot rely on geriatricians, internists, and family practitioners alone in the medical community to provide all of the geriatric care. Even though there are alternatives to the use of specialists, we cannot afford to ignore the largest group of current physician trainees who will provide a great deal of geriatric medical care in the future. We need to help make the basic principles of geriatric care part of every training program for every resident, whether in general or specialty programs.     

Depression in ethnically diverse women: Implications for treatment in primary care settings.

What do health care practitioners need to know about providing adequate care for depressed minority women? This article examined the prevalence of depressive symptoms and clinical depression in ethnic minorities, the extent to which current health service utilization is congruent with needs, and the effectiveness of treatments provided to ethnic minorities in the primary care setting. The impact of ethnic minority women's sociocultural context on symptom expression and help-seeking behavior is also discussed. Finally, the clinical implications for accurate assessment and treatment of ethnic minority women by both medical and mental health practitioners working in the primary care sector are addressed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Early abortion. Update and implications for midwifery practice

Medical abortion using methotrexate and misoprostol and manual vacuum aspiration are two new methods for pregnancy termination during the first 8 weeks of gestation. Compared to the regimen of mifepristone (RU 486) and misoprostol, both methods offer high rates of complete abortion and acceptability to users. Limitations of the new two-drug regimen compared with mifepristone include a longer time to effect abortion, transient gastrointestinal side effects, and risk of potential teratogenicity from methotrexate's cytotoxicity. Compared to standard surgical abortion, both methods allow women to avoid surgery, are more privately performed, and may be more easily accessible. The safety of first-trimester abortion provided by nurse practitioners and physician assistants has been established. Whether midwives and either new method to their practices depends on several factors. These include obtaining appropriate training, overcoming legal restrictions, and meeting professional and personal challenges inherent in providing early abortion care.     

Member ratings of health care provided by 48 physician groups

BACKGROUND: Satisfaction with health plan performance has been assessed frequently, but assessment of physician group performance is rare. OBJECTIVE: To present ratings of the care provided by physician groups to enrollees in a variety of capitated health maintenance organization plans. METHODS: A random sample was drawn of adult enrollees receiving managed health care from 48 physician groups in a group practice association. Each individual in the sample was mailed a 12-page questionnaire and 7093 were returned (59% response rate). The mean age of those returning the questionnaire was 51 years; 65% were women. RESULTS: Reliability estimates for 6 multi-item satisfaction scales were excellent, and noteworthy differences in ratings among groups were observed. In particular, ratings of overall quality ranged from a low of 28 to a high of 68 (mean, 50; SD, 10). Average scores for physician groups were strongly correlated across all scales, but no single group scored consistently highest or lowest on the different scales. Negative ratings of care were significantly related to the following: intention to switch to another physician group, difficulty in getting appointments, lengthy waiting periods in the reception area and examination room, the inability to get consistent care from one physician for routine visits, and not being informed by the office staff when there was a delay in seeing the primary care provider. CONCLUSIONS: Monitoring of health care quality at the physician group level is possible, and could be used for benchmarking, internal quality improvement, and for providing information to the public about how these physician groups will meet its needs.     

The effect of gastroenterology training on the efficiency and cost of care provided to patients with diverticulitis

BACKGROUND & AIMS: National trends emphasize the need for cost-efficient medical care with no diminution in quality. The most appropriate role for various physician groups has yet to be determined. The aim of this study was to investigate the efficiency of medical care provided by family practitioners (FPs), internists (IMs), and gastroenterologists (GIs) for acute diverticulitis. METHODS: All medicare hospitalizations from 1990 to 1993 in Illinois caused by acute diverticulitis, with FPs, IMs, or GIs as the primary attending physician, were included in the study. RESULTS: The primary attending physician was an FP in 1019 cases, an IM in 2535 cases, and a GI in 163 cases. The age and sex distributions were similar. The length of stay was significantly shorter (P < 0.0001) for GIs (7.4 +/- 6 days) than for FPs (7.9 +/- 14 days) or IMs (8.6 +/- 7 days). Readmission rate was significantly less (P < 0.03) for GIs (4.5%) than for FPs (7.7%) or IMs (10.0%). No significant differences were noted in complication rates or mortality. CONCLUSIONS: Patients with diverticulitis treated by GIs have a shorter hospital stay and a lower risk for readmission than patients treated by FPs or IMs. This improved quality of care should be considered by managed care organizations because they decide the role of various physician groups.     

Exploring cost and quality: community-based versus traditional hospital delivery systems

This article presents two approaches for comparison studies of cost and quality outcomes between community-based and traditional hospital systems of care. Two methodologies are used specifically to compare midwifery practice in a free-standing birth center to traditional obstetric practice with hospital deliveries. Findings from both studies reinforce the potential cost savings of community-based care without compromising quality. The methodologies used here can be applied to other settings. These approaches are also relevant for comparison studies of cost and quality outcomes between physicians and other nonphysician providers such as physician assistants and nurse practitioners, who frequently staff emerging models of community-based care. Issues related to obtaining comparable clinical and cost data versus reimbursement for both community-based and hospital care will be highlighted.     

Relationship of provider characteristics to outcomes, process, and costs of care for community-acquired pneumonia

OBJECTIVES: The authors describe the relation of provider characteristics to processes, costs, and outcomes of medical care for elderly patients hospitalized for community-acquired pneumonia. METHODS: Using Medicare claims data, Medicare beneficiaries discharged from Pennsylvania hospitals during 1990 with community-acquired pneumonia were identified. Claims data were used to ascertain mortality, readmissions, use of procedures and physician consultations, and the costs of care. The relationship of these measures to provider characteristics was analyzed using regression techniques to adjust for patient characteristics, including comorbidity and microbial etiology. RESULTS: Among 22,294 pneumonia episodes studied, 30-day mortality was 17.0%. After adjusting for patient characteristics, 30-day mortality and readmission rates were unrelated to hospital teaching status or urban location or to physician specialty. Use of procedures and physician consultations was more common and costs were 11% higher among patients discharged from teaching hospitals compared with nonteaching hospitals. Similarly, costs were 15% higher at urban hospitals compared with rural hospitals. General internists and medical subspecialists used more procedures and had higher costs than family practitioners. CONCLUSIONS: Processes and costs of care for community-acquired pneumonia varied by provider characteristics, but neither mortality nor readmission rates did. These differences cannot be explained by clinical variables in the database. Further studies should determine whether less costly patterns of care for pneumonia, and perhaps other conditions, could replace more costly ones without compromising patient outcomes.     

Supraannular aortic root enlargement in patients with small aortic annulus: efficacy and safety

In response to several women who presented with postpartum depression in 1 year, a group of nurses developed a task force made up of hospital nurses, obstetricians, psychiatrists, pediatricians, family practitioners, lactation specialists, home care nurses, and mental health counselors. The purposes of this task force were to educate health care professionals about postpartum depression, to help identify women who might be affected, and to develop interventions for adjusting to parenthood. This article details the evolution of that task force, and how it has assisted not only the women but also the health care providers involved.     

Comparative costs to the Medicare program of seven prepaid group practices and controls

This research was conducted in order to compare costs to the Medicare program for providing health care service to old people enrolled in two forms of health delivery organization: open market and prepaid group practice (pgp). Two data sources were employed: cost data provided by the Social Security Administration for seven prepaid group practices in five SMSAs and northern California and interviews conducted with administrators of the prepaid groups to determine: organizational sponsorship, incentive structure, pattern of selectivity of patients, and resource availability. Major findings are: (1) Enrollees in prepaid groups incur higher physician costs. This includes services provided by practitioners in and outside the plans. (2) Overall, prepaid groups demonstrate savings to the Medicare program in provider-initiated services- in hospital care and extended care facility services, but not in home health care. (3) Reduced spending in the hospital component does not imply reduction in the extended care facility or home service. (4) Outpatient costs in the hospital are generally higher in the open market modes, probably because this mode of care is viewed as an alternative to physician visits. (5) The greatest cost savings to the Medicare program are demonstrated by groups which are relatively small, yet hospital-based.     

Integrating mental health services into primary medical care

Primary care clinicians occupy a strategic position in relation to the emotional problems of their patients. Integrating mental health and primary medical services promotes available, coordinated, accessible, and less stigmatizing treatment by recognizing an indivisibility of the total person in illness and in health. Federal efforts to encourage Health Maintenance Organization (HMO) development as part of a national health program prompts serious attention to organizational arrangements for developing such an integrated program for medical-mental health care. We have found a team collaborative model in which mental health providers are members of a primary care team to be useful and promising. Supportive services are provided on a continuing basis through patterned relationships. Shared responsibility for patient care between physicians, nurse practitioners, physician assistants, and mental health workers provides built-in peer review and encourages intrateam consultation.     

Systemic diseases in elderly dental patients

There has been increasing interest in gender disparities in clinical decisionmaking. Few studies have examined this issue in nationally representative samples or focussed on primary care. In addition, few of the studies have examined the role of physician gender. The 1987 National Medical Expenditure Survey was used to examine the relationship between physician gender and screening deficiency in women for three gender-sensitive tests (breast examinations, Papanicolaou tests, and mammograms) and one gender-neutral test (blood pressure checks). Women reporting a female physician as their usual provider compared with those reporting a male physician were less likely to be deficient for Papanicolaou tests and mammograms. There was a smaller, but nonsignificant similar trend for breast examinations. No gender bias was evident for blood pressure checks. These results persisted after multivariate adjustment for patient age, race, education, income, insurance status, subjective health status, other health behaviors, and attitude toward health care and health insurance. The results confirm the existence of physician gender bias in clinical decision making and represent one area for quality improvement.     

Consultations with practitioners of alternative medicine

More than 2,000 Jewish adults, aged 45-75, in urban areas of Israel were interviewed regarding consultations with practitioners of alternative medicine. 6% (122) of the respondents reported visiting such practitioners in the year prior to the interview. Homeopathy was the most frequent therapy, followed by reflexology, naturopathy, and acupuncture. The most common medical complaint was pain, particularly back pain. The most frequent reason for consulting the practitioner was disappointment with the outcome of conventional treatment. 39% of respondents who visited a practitioner were being treated by a conventional physician at the same time, for the same problem. The medical problems of a large majority had been relieved, but 22% said they were not helped by the practitioner. Women were more likely than men to consult a practitioner. Respondents with secondary or higher education were more likely to visit than those with less education. There were no age or socio-economic differences between users and nonusers. The mean payment for the whole series of treatments was NIS 770 (about $250). Respondents who visited practitioners reported worse health and more pain than nonusers, and were also more likely to have visited their conventional primary care physician in the past month. The findings suggest that nonconventional medicine should be seen as complementary to, rather than in competition with conventional medicine.     

Pregnancy in diabetic patients. A calculated risk

In general, a diabetic woman may count upon delivering a healthy child--provided optimal antenatal care. Success or failure of pregnancy will in the individual case decisively depend on the experience and efforts of the attending physician. The directives for the care of pregnant diabetic women as practiced at the II. Univ.-Frauenklinik München are demonstrated.     

Magnetic-field Exposures in the Workplace: Reference Distribution and Exposures in Occupational Groups

This study projects that the per capita supply of alternative medicine clinicians (chiropractors, naturopaths, and practitioners of oriental medicine) will grow by 88 percent between 1994 and 2010, while physician supply will grow by 16 percent. This increase is associated with growth in the number and size of alternative medicine colleges and in the opportunities these graduates have for licensure and practice. This study calls for an assessment of the education and regulation of clinicians across the range of disciplines who will be providing patient care in the twenty-first century.     

Managed care and the treatment of skin disease, 1995. Continued growth and emerging dominance

OBJECTIVE: To document changes in type of financing for office-based visits for the treatment of common skin conditions and to dermatologists. DESIGN: Data from a national survey of visits to office-based practitioners conducted by the National Center for Health Statistics were used. The stratified sampling technique permits estimation of the total number of office visits with specific characteristics in the United States. SETTING: A national probability sample of visits to office-based practitioners occurring in 1995. SUBJECTS: In 1995, 36,875 visits were sampled. Of these, 2121 were for common skin problems to any physician and 1886 were visits for any reason to dermatologists. MAIN OUTCOME MEASURES: The distribution source of payment and presence of managed care arrangements for office visits for common skin problems and to dermatologists. INTERVENTION: None. RESULTS: In 1995, preferred provider and health maintenance organizations provided payment for 34% of all ambulatory care and 38% of office visits for common skin complaints. CONCLUSION: Managed care is already the dominant mechanism of payment for the treatment of skin disease for many patient groups and in many areas of the country. Preferred provider organizations are much more likely to employ dermatologists to provide care of common skin problems than are health maintenance organizations. If the recent trends continue, by year 2000 most patients seen by dermatologists will be seen under the auspices of managed care systems.     

The policy implications of using hospital and physician volumes as "indicators" of quality of care in a changing health care environment

There is growing interest in the quality of health care and in using quality measures to direct patients to hospitals and providers offering high quality, low cost health care. The dilemma is that, while there is an increasing need for quality indicators as a result of a changing health care environment, this changing environment has important implications for the use of some of these measures. Since the 1970s, a growing body of research in the U.S. has addressed the empirical relationship between the number of patients with a specific diagnosis of surgical procedure and their outcomes after treatment in a particular hospital or by a particular physician ("volume-outcome" studies). In this paper, we examine the policy implications of using hospital and physician volume information as an "indicator" of quality in a rapidly changing health care environment with new players and new incentives. We begin by describing the evolution of the use of volumes within both regulatory and market-oriented contexts in the U.S. We then discuss policy considerations and cautions in using volumes, along with suggestions for future research. Our purpose is to point out potential problems and clarify confusions about the use of volumes, so that policymakers and practitioners can be sensitive to the potential minefields they are traversing.     

Applying behavioral research to incontinence

Historically, treatment strategies for urinary incontinence (UI) have not been offered by primary care practitioners. This is despite the fact that prevalence for UI in women of all ages has been reported to be as high as 30 percent and that there are interventions, specifically behavioral treatments, that can be integrated in a primary care practice. However, most practitioners have not been trained in identification of UI, causes and approaches that can be incorporated into a successful treatment program. The authors have implemented a program to address the problem of UI. This article outlines their successful application of a behavioral therapy protocol in two diverse practices: gynecological and internal medicine.     

The culture of female circumcision

The issue of female circumcision takes on special significance as more women migrate to the United States from countries where the practice has religious and traditional underpinnings. Female circumcision is a problem unfamiliar to most Western health care practitioners. This article describes an ethnographic study of the types of female circumcision, the reasons for and against the practice, the health implications of this practice, and cultural attitudes of circumcised women both in Western Africa and as migrant refugees living in the United States. Ethical dilemmas in dealing with this practice and implications for nurses and health care providers are discussed.